Blog | Wednesday, September 4, 2013

Why are we so terrible at hand hygiene?


Atul Gawande has a piece in the New Yorker titled “Slow Ideas” that asks why some innovations (and yes, the act of cleaning hands was once an innovation) are so slow to catch on. He starts the piece by comparing two mid-1800s innovations, anesthesia and surgical antisepsis, and outlining reasons why the former spread so much more readily than the latter.

“So what were the key differences? First, one combatted a visible and immediate problem (pain); the other combatted an invisible problem (germs) whose effects wouldn’t be manifest until well after the operation. Second, although both made life better for patients, only one made life better for doctors. Anesthesia changed surgery from a brutal, time-pressured assault on a shrieking patient to a quiet, considered procedure. Listerism, by contrast, required the operator to work in a shower of carbolic acid. Even low dilutions burned the surgeons’ hands. You can imagine why Lister’s crusade might have been a tough sell.”

These simple observations are highly relevant to hand hygiene, an innovation that still hasn’t completely taken hold after 150 years. Microorganisms are invisible to the naked eye, the diseases they cause have incubation periods that separate cause (poor or absent hand hygiene) from effect (infection, sepsis, death), and an individual failure of performance is almost never linked directly to the adverse outcome. The alternatives to what we’ve been doing (constantly-evolving campaigns that have impacts which extinguish over time) involve long-term, multi-faceted approaches that have the goal of eventually “hard-wiring” the behavior.

Daniel J. Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. This post originally appeared at the blog Controversies in Hospital Infection Prevention.